PRACTICE RECOMMENDATIONS
• Screen patients for substance use disorders, with a single (validated) question for alcohol and another for drugs. A
• Follow a positive screen for alcohol with an assessment to distinguish between hazardous drinking and drinking that is indicative of alcohol dependence. C
• Approach a substance use disorder as you would any chronic medical condition, seeking to engage the patient to encourage behavior change. Motivational interviewing is a useful tool. C
• Consider pharmacotherapeutic options for patients with alcohol or drug dependence. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Episodic heavy drinking, like alcoholism and drug addiction, is increasingly recognized as a medical problem that primary care physicians can, and should, address.1 But it is rarely the chief reason for an office visit. Nor is it a subject patients are likely to bring up.
However, patients are generally willing to talk to a trusted doctor who asks about their use (or misuse) of alcohol or other substances. And primary care physicians can do much to help—with brief interventions, a growing armamentarium of pharmacotherapy, and referrals as needed. In the pages that follow, you’ll find easy-to-use screening tools and effective intervention strategies.
SCREENING NEEDN'T BE TIME-CONSUMING
Screening for substance use isn’t difficult. In fact, it can usually be accomplished with 2 targeted questions—one for alcohol use and one for drugs.
Alcohol. Two single-question screens to detect hazardous drinking have been validated, despite having different parameters. Ask either:
Q: When was the last time you had more than ____ drinks (4 for women and 5 for men) in one day?
or
Q: How many times in the past year have you had ___ or more drinks (4 for women and 5 for men) in one day?
For the first question, any answer within the past 3 months is a positive screen for hazardous drinking.2 For the second, anything other than zero is positive.3,4
Initial screening can also be done with the AUDIT-C (TABLE), a validated short (3-question) version of the Alcohol Use Disorders Identification Test that can be self-administered.5,6
Drugs. Only one single-question screen for drug use has been validated:
Q: How many times in the past year have you used an illegal drug or taken a prescription medication for nonmedical reasons?
Any answer other than never is a positive screen for hazardous drug use.7
CASE Jason F, a healthy and fit 28-year-old, has been your patient, along with his family, for years. He’s in your office because of a knee injury he incurred while running, and you take a moment to ask him, for the first time, how much he drinks and whether he takes drugs. His answer—that he drinks 3 or 4 times a week and often has multiple drinks at parties or nights out with the guys—takes you a bit by surprise.
Now what?
TABLE
3-question AUDIT-C screen for alcohol dependence5,6
| 1. How often do you have a drink containing alcohol? | ||
| 0 Never | 3 2 to 3 times a week | |
| 1 Monthly or less | 4 4 or more times a week | |
| 2 2 to 4 times a month | ||
| 2. How many drinks containing alcohol do you have on a typical day when you are drinking? | ||
| 0 I don’t drink. | 2 5 or 6 | |
| 0 1 or 2 | 3 7 to 9 | |
| 1 3 or 4 | 4 10 or more | |
| 3. How often do you have 6 or more drinks on one occasion? | ||
| 0 Never | 3 Weekly | |
| 1 Less than monthly | 4 Daily or almost daily | |
| 2 Monthly | ||
| Scoring the AUDIT-C | ||
| Alcohol dependence | ||
| Men | Women | |
| Threshold score | 5 | 4 |
| Sensitivity (%) | 80 | 76 |
| Specificity (%) | 74 | 78 |
| AROC | 0.769 | 0.767 |
| AROC, area under the receiver operating characteristic curve; AUDIT, Alcohol Use Disorders Identification Test. | ||
TELL ME MORE ABOUT IT
It is important to respond to a positive screen by requesting more information. In the conversation that ensues, the patient may provide the details you need to determine whether the drinking or drug use is indicative of a diagnosable substance use disorder, an umbrella term for alcohol or drug abuse and alcohol or drug dependence.
Alcohol or drug abuse vs dependence. Criteria for alcohol or drug abuse in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) include risky behavior, such as drinking and driving; problems with work and/or close relationships; or run-ins with the law, such as an arrest for driving while intoxicated. Criteria for alcohol or drug dependence include the inability to cut down or stop using the substance; evidence of tolerance and withdrawal; spending more time ingesting the substance; increasing attention to substance use while interest in other activities diminishes; and continued use despite recurrent problems.8